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APPLICATION FROM FOR PREFERRING COMPENSATION CLAIM
(Claims for Damage/ Shortage/Loss/Non Delivery of Goods/ Parcel /Luggage)

CAUTION: - As per section 149 of the Railways ACT, 1989,if any person requiring compensation from a railway administration for loss, destruction, damage, deterioration or non-delivery of any consignment makes a claim which is false or which he knows or believes to be false or does not believe to be true, he shall be punishable with imprisonment for a term which may extend to three years, or with fine, or with both.

To be filled in by Claim Office 

 

Received on

 

 

 

 

 

 

 

 

Claim no

 

 

 

 

 

 

 

 

 

 

 

 

                         D    D    M   M Y    Y    Y   Y

Whether particulars adequate?

 

 

                                                Yes   No

Claim File No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                   Type  /  Section  / Dealer  /  Dest Stn  ./  Off Code  /   Month  /  Finance

 

 

The Chief Comml. Manager (Claims)

South Eastern Railway

14 th Strand Road (10th Floor)………………………………

Kolkata-1………………………………..

Dear Sir,

Under Section 106 of Railways Act 1989, I/We prefer a claim on the --------------------------- Railway particulars of which are detailed below .

1. Amount Claimed Rs.

 

 

 

 

 

 

 

 

 

2. Reference No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dated       

 

 

/

 

 

/

 

 

 

3. Party code

 

 

4. Name of  claimant     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Postal Address                        

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

Pin

 

 

 

 

 

 

 

Telephone /E-Mail

 

 

 

 

 

 

 

 

 

6.Document of Booking

             Railway Receipt

 

Parcel Way Bill

 

FSLA

 

(Tick & fill in as applicable)

Luggage Ticket

 

 

Soldier Ticket

 

Others

 

Document Number:

 

 

 

 

 

 

 

7. Date of Booking

 

 

/

 

 

/

 

 

 

8. Booking Station

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Destination Station

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. First Via Station

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. Second Via Station

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Freight                                                                                      Paid

 

 

                                                                                                     To Pay

 

 

13. Name of Consignor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Name of Consignee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14A. Is Consignee?           (a) Military (b) Railway Department (c) FCI (d) Government

           
                                          (e) Govt. Undertaking ( f) Others

       
                                               (Ticket whichever is applicable)

15.Title of Claimant :(a) Consignor,(b)Consignee,(c ) Endorsed Consignee (d)Insurance Company, (e ) Others

      
                                                                   ( Tick whichever is applicable)

16. Commodity Booked

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

        Commodity Code

 

 

 

                 No. of Packages

 

 

 

 

 

 

17. In case of Wagon Load                                       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
                                                         Owning Rly                                            Wagon No                                                               Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

      
                                                        Owning Rly                                               Wagon No                                                                Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
                                                        Owning Rly                                               Wagon No                                                                    Type

   
                                                                                          ( Ifmore than three, attach separate Sheet)

 

18.Booked on

 

 

 
                                                            Railway Risk                                         Owner’s Risk                  ( Tick whichever is applicable )

19. Value Declared Rs.

 

 

 

 

 

 

 

 

 

 

 

20. Percentage Charges paid?

 

 

 

 
                                                                                     Yes                                                              No

21. Cause of Claim

 

 

 

 

 

      
                                                         Non – Delivery                                                 Damage by Fire                                 Shortage

 

(Tick whichever is applicable)

 

 

 

 

 

 

  
                                                               Breakage                                                     Loss of complete package                        Leakage

 

 

 

 

 

 



                                                                             Damage by wet                                         Damage due to Delay                               Others
 

22. Details of loss /Shortage / Damage etc. | If loss – state no. of packages / Bags lost

 

 

 

 

 

If shortage – State Quantity (Tonnes/ Qtls. / Kgs.)

 

 

 

 

 

Whether Rly. has certified the said Loss / shortage / Damage etc.? 

 

 

 


                                                                                                                                                                  Yes                    No

23. Train No. by which dispatched (if know)

 

 

 

 

 

 

Dated

 

 

/

 

 

/

 

 

                                                                                                                         D  D          M   M          Y    Y

24.Whether notice of claims under 106 IRA has already been given?

 

 

 

                                                                                                                      Yes                       No

25.If Yes Notice No              

 

 

 

 

 

 

 

 

 

 

                                   Dated

 

 

/

 

 

/

 

 

                                                                                                                                                                            D      D     M       M         Y        Y

26.Full particulars of contents of the damaged packages showing the value of each article.

27 Remarks, if any.

28 Enclosures (Tick the relevant item)

(1) RR/PWB/FSLA/LT/ST/Others (2) Beejuck Bill (Original) (3) Colliery Bill (Original)(4) TDS/Valuation Statement (in Duplicate). (5) Open /Short Delivery Certificate.(6) Assessment Report/Certificate.(7) Letter of Authority.(8) Subrogation & Special Power of Attorney (9) Gate Pass / PDC. (10) Claim Bill.(11) Undertaking by Claimant. (12) Bank Details.(13) Others (Please Specify).

 
                                                                                                                         SIGNATURE OF THE APPLICANT




Source : South Eastern Railway CMS Team Last Reviewed on: 04-09-2013  


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